Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID R3332-001-000
Plan Organization Florida Blue
Plan Type Regional PPO
Plan Name BlueMedicare Choice (Regional PPO)
Plan Organization Type Regional CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $47.90
Total Premium (Includes Part B) $183.40
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $47.90
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $47.90
Monthly Part D Premium Full Assistance $17.10
Monthly Part D Premium 75% Assistance $24.80
Monthly Part D Premium 50% Assistance $32.50
Monthly Part D Premium 25% Assistance $40.20
Part D Drug Deductible $250.00
Annual Drug Deductible $250.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6500.00
Gap Coverage Yes

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 50% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 50% coinsurance
Lab services - Out-of-Network Yes No 50% coinsurance
Outpatient x-rays - Out-of-Network Yes No 50% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 50% coinsurance per visit
Specialist - Out-of-Network No No 50% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $50 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No 50% coinsurance
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $250 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $950 annual deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes Out-of-Network No No 50% coinsurance
Hearing aids Yes Out-of-Network No No 50% coinsurance
Hearing exam - Out-of-Network No No 50% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $495 per day for days 1 through 27$0 per day for days 28 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network$6,500 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 50% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 50% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 50% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 50% coinsurance
Other Part B drugs - Out-of-Network Yes - 50% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $495 per day for days 1 through 27$0 per day for days 28 through 90
Outpatient group therapy visit - Out-of-Network Yes No $40-150 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No $40-150 copay
Outpatient individual therapy visit - Out-of-Network Yes No $40-150 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No $40-150 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 50% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 50% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning No - - - Not covered
Dental x-ray(s) No - - - Not covered
Fluoride treatment No - - - Not covered
Oral exam No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No 50% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 50% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $250 per day for days 1 through 58$0 per day for days 59 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam Yes Out-of-Network No No 50% coinsurance
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Alachua County, Florida, Baker County, Florida, Bay County, Florida, Bradford County, Florida, Brevard County, Florida, Broward County, Florida, Calhoun County, Florida, Charlotte County, Florida, Citrus County, Florida, Clay County, Florida, Collier County, Florida, Columbia County, Florida, De Soto County, Florida, Dixie County, Florida, Duval County, Florida, Escambia County, Florida, Flagler County, Florida, Franklin County, Florida, Gadsden County, Florida, Gilchrist County, Florida, Glades County, Florida, Gulf County, Florida, Hamilton County, Florida, Hardee County, Florida, Hendry County, Florida, Hernando County, Florida, Highlands County, Florida, Hillsborough County, Florida, Holmes County, Florida, Indian River County, Florida, Jackson County, Florida, Jefferson County, Florida, Lafayette County, Florida, Lake County, Florida, Lee County, Florida, Leon County, Florida, Levy County, Florida, Liberty County, Florida, Madison County, Florida, Manatee County, Florida, Marion County, Florida, Martin County, Florida, Miami-dade County, Florida, Monroe County, Florida, Nassau County, Florida, Okaloosa County, Florida, Okeechobee County, Florida, Orange County, Florida, Osceola County, Florida, Palm Beach County, Florida, Pasco County, Florida, Pinellas County, Florida, Polk County, Florida, Putnam County, Florida, Saint Johns County, Florida, Saint Lucie County, Florida, Santa Rosa County, Florida, Sarasota County, Florida, Seminole County, Florida, Sumter County, Florida, Suwannee County, Florida, Taylor County, Florida, Union County, Florida, Volusia County, Florida, Wakulla County, Florida, Walton County, Florida, Washington County, Florida

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